BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, MYSORE-570023

CONSUMER COMPLAINT NO.60-2021

DATED ON THIS THE 29^th November 2022

Present:   1) Sri. B.Narayanappa

M.A., LL.B., - PRESIDENT  

                     2) Smt.Lalitha.M.K.,

M.A., B.A.L., LL.B., - MEMBER  

                        3) Sri Maruthi Vaddar,

                                                B.A., LLB (Special)  - MEMBER

Sri B.NARAYANAPPA,

PRESIDENT

1.       The complainant Smt.Poornima.H resident of Mysuru has filed this complaint against the OP No.1- The Manager, M/s Star Health and Allied Insurance Company Limited, Chennai and OP No.2- The Manager, M/s Star Health and Allied Insurance Company Limited, Mysuru praying to direct the OPs to pay a sum of Rs.1,72,093/- along interest at 18% p.a. from 17.05.2020 till realization and also direct the OPs to reinstate the policy bearing No.P/141138/01/2020/008259 by taking back the D.D. bearing No.762431 dated 09.10.2020 to the tune of Rs.9,978/- paid towards annual premium, and to pay Rs.1,50,000/- towards mental agony and harassment caused to complainant and Rs.40,000/- towards litigation expenses and Rs.50,000/- to Consumer Welfare Fund and to grant such other reliefs as this Commission deems fit to grant.
2.       The brief facts are that:-

The complainant has obtained the health insurance policy bearing No.P/141138/01/2020/008259 from OPs.The date of inception of the policy is 09.03.2020 and the same is valid from 09.03.2020 to 08.03.2021 on payment of premium on yearly basis. The complainant got her mother Smt.Bharati insured under the policy. On 17.05.2020 the mother of the complainant Smt.Bharathi complained of breathlessness.Hence, she took treatment in JSS Hospital, Mysuru as inpatient from 17.05.2020 and she was discharged on 30.05.2020.After discharge, the complainant sent claim form to OPs along with relevant documents in the month of July 2020.The OPs assured to settle the claim, but vide their letter dated 31.08.2020 repudiated the claim stating that the mother of the complainant was suffering from pre-existing disease prior to commencement of the policy, for non-disclosure of the same, claim has been rejected.Therefore, it is alleged deficiency in service on the part of OPs.The mother of the complainant was hail and healthy and she was not suffering from any pre-existing disease and the OPs vide their letter dated 13.10.2020 has intimated the complainant stating that the policy has been cancelled and refunded the premium vide D.D.No.762431 dated 09.10.2020.Therefore, it is alleged that the act of the OPs are arbitrary and unlawful.Hence, this complaint.

3.       After registration of this complaint, notices were ordered to be issued to OPs.  In response to notices, OPs appeared before this Commission through their counsel and has filed a memo dated 18.08.2021 stating that the OPs are ready to settle the claim for Rs.83,558/- and will restore the policy.  But, OPs did not file the version. The complainant not accepted the settlement offered by the OPs and has filed her affidavit by way of examination in chief and same was taken as P.W.1 and got marked the documents as Ex.P.1 to Ex.P.10.  On the other hand, the OPs have also filed affidavit by way of examination in chief and same was taken as R.W.1.
4.       We have heard the arguments of both sides.  On behalf of both parties, their counsels have filed their respective written arguments.    
5.        The points that would arise for our consideration are as under

1. Whether the complainant proves that the alleged deficiency in service on the part of the opposite parties and thereby she is entitled to the reliefs as sought for?
2.  What order?

6.       Our findings on the aforesaid points are as follows:

      Point No.1 :- Partly in the affirmative.

      Point No.2 :- As per final order for the following

:: R E A S O N S ::

7.          Point No.1:- It is not in dispute that the complainant had obtained health insurance policy from OP bearing No.P/141138/01/2020/008259 which is valid from 09.03.2020 to 08.03.2021 and the complainant got her mother Smt.Bharathi insured under the said policy which is in the name and style “Senior citizen Red Carpet Health Insurance Policy” and it is the specific contention of the complainant that on  17.05.2020 her mother complained of breathlessness. Therefore, she was admitted to JSS Hospital, Mysuru on 17.05.2020 and after treatment she was discharged on 30.05.2020 and spent medical expenses of Rs.1,72,093/- and made claim form with OPs along with relevant documents, though OPs assured to settle the matter, but repudiated the claim vide its letter dated 31.08.2020 on the ground that the mother of the complainant was suffering from pre-existing disease prior to inspection of the policy and non-disclosure of the same resulted in rejection of the claim of the complainant. 
8. The complainant produced Star Health and Allied Insurance policy issued by OPs bearing No.P/141138/01/2020/008259 valid from 09.03.2020 to 08.03.2021.  Therefore, it is crystal clear that during the date of validity of policy the mother of the complainant took treatment, the policy in question was in force and effective and the said policy covers the insured Smt.Bharathi who is none other than the mother of the complainant and the sum assured is Rs.2,00,000/- and it is crystal clear from the insurance policy that the OPs have clearly mentioned details of pre-existing disease relating to the above person namely Smt.Bharathi as Nil.  So from the contents of the Star Health and Allied Insurance policy issued by OPs, it is crystal clear that the mother of the complainant by name Bharathi was not suffering from any pre-existing disease as mentioned in the policy issued by OPs themselves. The complainant also produced discharge summary issued by JSS Hospital dated 17.05.2020 which shows that the mother of the complainant was admitted to hospital on 17.05.2020 in JSS Hospital, Mysuru and was discharged on 30.05.2020 with history that No history of fever, chest pain, No history of palpitations, no history of orthopnoea/PND, history of disturbed sleep and snoring present.  From the discharge summary, it is crystal clear that the complainant was not suffering from any pre-existing disease, at the time of admission to JSS Hospital, she has only complained of disturbed sleep and snoring present which cannot be said that the mother of the complainant was suffering from pre-existing disease.  It is pertinent to mention here that the OPs not only repudiated the claim of the complainant, but also cancelled the insurance policy bearing No.P/141138/01/2020/008259 and returned the premium amount of Rs.9,978/- paid by the complainant.  From the memo dated 18.08.2021 filed by OPs, it is crystal clear that the OPs offered settlement for Rs.83,558/- and to restore the policy. Under such circumstances, the repudiation of the claim by OPs on the ground that the mother of the complainant was suffering from pre-existing disease is appears to be fishy and it shows that according to the whims and fancy, the OPs have repudiated the claim and cancelled the insurance policy issued to complainant, but come forward to settle the claim for Rs.83,558/-. The settlement arrived at Rs.83,558/- has no basis.  Therefore, the complainant did not agree for the settlement offered by the OPs.  The complainant produced letter issued by OPs dated 13.10.2020 which clearly goes to show that the OPs vide their letter dated 13.10.2020 cancelled the policy issued to complainant and returned back the DD No.762431 dated 09.10.2020 drawn for Rs.9,978/- for payment of premium which appears tobe unjustified on the part of OPs.  The act of the OPs that repudiating of the claim of the complainant vide their letter dated 31.08.2020 and cancellation of the policy issued to complainant vide letter dated 13.10.2020 and after, filing the present complaint came forward to settle the claim for Rs.83,558/- appears to be unjustifiable act which is nothing but deficiency in service and unfair trade practice committed by the OPs.
9. The complainant produced statement form issued by JSS Hospital, Mysuru showing the hospital expenses of Rs.1,72,093/-.  The said statement is not a computerized statement, but it is a hand written statement which cannot be considered as gospel truth.  Any way considering the admissible and in-admissible charges levied by the JSS Hospital, Mysuru we are of the considered view that if an amount of Rs.1,10,000/- is awarded, and the OPs are directed to reinstate the policy, it will meets the ends of justice.  On going through the complaint averments and the memo filed by the OPs dated 18.08.2021 offering the settlement for Rs.83,558/- and the documentary evidence produced by the complainant, we are of the considered view that the complainant has proved the alleged deficiency in service on the part of OPs. Hence, we answer point No.1 partly in the affirmative.
10.       Point No.2:- For the aforesaid reasons, we proceed to pass the following

:: ORDER ::

1. The complaint of the complainant is hereby allowed in part.
2. The opposite parties are hereby directed to pay a sum of Rs.1,10,000/- to the complainant towards medical expenses incurred by the complainant for the treatment of her mother Smt.Bharathi with interest at 10% p.a. within 2 months from the date of this order.
3. Further opposite parties are hereby directed to reinstate the policy in question by taking back the D.D. of HDFC Bank No.764231 dated 09.10.2020 to the tune of Rs.9,978/- and to pay compensation of Rs.10,000/- towards mental trauma caused to complainant and deficiency in service and Rs.5,000/- towards cost of the litigation to the complainant within 2 months from the date of this order.  Failing which, the compensation of Rs.10,000/- + cost of litigation Rs.5,000/- = Rs.15,000/- shall carry interest at 10% p.a. till payment.
4. The complainant is at liberty to take action against the opposite party under Section 72 of the C.P.Act, 2019 for non-compliance of this order.
5. Furnish the copy of order to both parties at free of cost.

(Dictated to the Stenographer transcribed, typed by her, corrected by us and then pronounced in open Commission on this the 29^th November 2022)